E-Check Autodraft Form

PLEASE READ BEFORE SUBMITTING FORM!!!!
I authorize the City of Richwood to begin deductions for my monthly utility bill with the financial institution named. Enrollment in the automatic payment plan may be discontinued any time by sending a request, in writing, to the City of Richwood. My authority will remain in effect until revoked by my financial institution, the City of Richwood, or myself. I understand that both my financial institution and the City of Richwood have the right to terminate this payment plan or my participation therein. I will be charged $25.00 if any of my payments are returned. If I have two insufficient bank drafts within one year, the City will terminate my enrollment in bank drafting.
PAYMENT WILL BE DRAFTED ON 10th of each month.

Name on utility account:

Utility Account Number:

Service Address:

Phone Number:

Email:

Financial Institution Name:

Financial Institution Address (City & State):

Account Type:

Checking Savings

Routing Number:

Bank Acount Number:

I authorize the City of Richwood to begin deductions for my monthly utility bill with the financial institution named. Enrollment in the automatic payment plan may be discontinued any time by sending a request, in writing, to the City of Richwood. My authority will remain in effect until revoked by my financial institution, the City of Richwood, or myself. I understand that both my financial institution and the City of Richwood have the right to terminate this payment plan or my participation therein. I will be charged $25.00 if any of my payments are returned. If I have two insufficient bank drafts within one year, the City will terminate my enrollment in bank drafting. PAYMENT WILL BE DRAFTED ON 10th of each month.

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E-Check Autodraft Form

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